Geriatric Advanced Practice Provider

About the role

The owns the full scope of advanced practice duties for a complex aging population within the MHN care management framework. In this capacity, you will conduct comprehensive clinical assessments that emphasize chronic disease oversight, functional capacity, cognitive status, and medication optimization for elderly patients. You will lead the development and execution of individualized, patient-centered care plans in active partnership with patients, their caregivers, and interdisciplinary colleagues across Springfield and Decatur sites. This role provides direct leadership in guiding care management initiatives that align with MHN's organizational goals for comprehensive and compassionate delivery. You will deliver primary and preventive services specifically tailored to the needs of adults enrolled in MHN health center contracts, ensuring high-quality, evidence-based care. A core responsibility includes performing detailed Annual Wellness Visits, incorporating health risk assessments and care planning to promote healthy aging and prevent avoidable decline. You will function as a key clinical expert, integrating best practices for geriatric care to support both patient well-being and system efficiency.

Key facts

What you'll do

• You will conduct thorough patient evaluations to identify medical, functional, and social needs.
• You will provide comprehensive primary and preventive care services to aging patients enrolled in MHN's contracted health centers.
• You will perform thorough assessments with a focus on chronic disease management, functional status, cognitive health, fall risk, and medication management.
• You will develop individualized, patient-centered care plans in collaboration with patients, caregivers, and interdisciplinary teams.
• You will lead the execution of Annual Wellness Visits (AWVs) in strict accordance with program guidelines.
• You will conduct Medicare Annual Wellness Visits, including completing required health risk assessments and care planning.
• You will utilize clinical decision-support tools to guide diagnosis, treatment pathways, and preventive service ordering.
• You will coordinate care transitions and communicate effectively with referral networks to ensure continuity and safety.
• You will document all clinical encounters accurately and in a timely manner within the electronic health record system.
• You will actively participate in quality improvement projects aimed at enhancing outcomes for geriatric populations.

Requirements

• You need a current, active Advanced Practice Provider license in the state of Illinois.
• You need a current, active registration as a Nurse Practitioner or Physician Assistant with the Illinois Department of Financial and Professional Regulation.
• You need Board Certification or Board Eligibility in a recognized primary care specialty such as Family Medicine, Internal Medicine, or Geriatrics.
• You need documented clinical experience in geriatric care or a strong focus on aging-related conditions.
• You need the ability to provide comprehensive primary and preventive care services to aging patients enrolled in MHN's contracted health centers.
• You need to perform thorough assessments with a focus on chronic disease management, functional status, cognitive health, fall risk, and medication management.
• You need to develop individualized, patient-centered care plans in collaboration with patients, caregivers, and interdisciplinary teams.
• You need to conduct Annual Wellness Visits (AWVs), including Medicare-covered health risk assessments and preventive services.
• You need strong knowledge of Medicare billing rules, wellness visit requirements, and compliance standards.
• You need excellent verbal and written communication skills to interface effectively with patients, families, and professional partners.

Nice to have

• Prior experience working within a value-based care model or accountable care organization.
• Familiarity with integrated behavioral health workflows and screening protocols.
• Experience with electronic clinical quality measures and reporting for geriatric populations.
• Demonstrated skill in care coordination across multiple provider sites and community resources.
• Background in health information technology, particularly with ambulatory EHR systems used in federally qualified health centers.
• Experience supporting medical education, such as supervising trainees or contributing to clinical curricula.

Practical notes

• Onsite work schedule is Monday through Thursday.
• Remote work is available on Friday for administrative tasks.
• This position is based at partner health center locations in Springfield and Decatur, Illinois.
• Travel between sites may be required depending on patient volume and operational needs.
• Full-time engagement with standard benefits eligibility upon meeting program criteria.
• Compliance with all organizational policies, including those related to confidentiality and professional conduct, is mandatory.